A fairly absurd argument that Dems’ health care reform bill will increase liberty from William Galston:
So when the Tea Partiers complain that a government health insurance mandate invades their liberty, they reveal a defective understanding of the logic of liberty in a modern society. Individuals who choose to go without health insurance could try to resolve the contradiction by signing a document foreswearing all reliance on health care they didn’t pay for themselves. But, because our medical norms don’t permit us to leave injured accident victims at the side of the road, such a document couldn’t be enforced. To be a citizen of the United States today is to live in a community where individual health care choices can have social consequences, a fact to which government can legitimately respond.
The obvious fallacy in this argument is that choosing not to insure against health care costs is not an announcement one will refuse to pay them when they are incurred, particularly in extremis. Rather than smiting such spurious strawmen, Galston might explain how a policy of throwing people in jail for not buying health insurance can be called consonant with maximizing liberty outside of an Orwell novel.
And such a policy is counterproductive anyway. Stephen Spruiell cites a Democrat who makes an relevant analogy to WalMart:
In most goods and services there are very few active consumers. What happens is, everybody selling a good is affected by Wal-Mart. You benefit from that wherever you are. So many of those who oppose consumer-driven health care use the perfect as the enemy of the good. You’re not going to shop for health care if you’re hit by a bus. That’s not the point. The point is you’re served in a health-care system that’s been tightened up, both from a cost and quality point of view, by the fact that some consumers, for many procedures, are shopping around, and not just on price.
The inefficient government is already paying for half or more of health care by some estimates, and insurance companies granted near-monopolies by state law cover all but a few percent of the rest. That’s not a recipe for driving efficiency, and the smaller we make the already-tiny fraction of people who are still incentivized to shop around for health care the worse off we’re all going to be in the end. The bill under consideration would make it zero.
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People are concerned about the “rising cost” of health care.
We’re not actually talking about addressing the cost, though.
What most people are seeing is the rising price of a bundle of pre-paid health care services. That is not the same thing as the cost of the underlying services. The bundling almost completely separates buyers from the actual cost of health care. Instead, they are sensitive only to bundling rules, and the cost basis for competition is heavily regulated out.
This is not even an accident. This is a deliberate policy decision to insulate people from the costs, and to enforce the notion that “money is no object”.
If you commit to building a system where “money is no object”, you will end up with a system capable of sucking down all available money.
As long as “money is no object”, the price and cost will continue to rise until we run out of all money.
Can you show me exactly where it says anyone goes to jail for not carrying health insurance? Please tell me this isn’t some strained “if you don’t pay your taxes you go to jail” thing, and it’s something more specific than that.
Also, if you’re so grossly irresponsible to society as a whole as to not carry health insurance and you get serious medical bills that you can’t possibly pay, what are the rest of us supposed to think of you? Oh, wait, no obligation to the rest of society and all that, every man is an island I suppose. Anyway, the point is, you’re evading the simple reality that young healthy people often wind up bills that they *can’t* pay, and we all suffer the costs of that. All of us.
There is some truth to this, but there are many problems with this.
There are is the cost of routine health care. There are opportunities for comparison shopping the cost of routine health care. There is, however, a major problem with this. When you shift most or all of the cost of routine health care on to the individual, they tend to skip it. They don’t get routine checkups. They don’t get their children vaccinated. This does not actually lower health care costs. It increases it.
The other problem is the cost of catastrophic health care. If you are in a auto accident or have a heart attack, you are not in a position to shop for the lowest cost treatment.
Clearly our current system is badly structured. We guarantee emergency medical treatment to everyone, regardless of their ability to pay, and we provide no mechanism for paying for it, so we all end up paying for it. But the big issue is the people do not really know what health care services they need, until it is too late. This allows medical service providers to manipulate the system to maximize their profits, with only the insurance companies and the government as a check on this (by refusing to pay).
Do you really think that allowing the individuals to make more of these decisions will reduce cost? Individuals are less knowledgeable than doctors or health insurance/government bureaucrats. Individuals are easily manipulated by advertising. Just look at what drug advertising has done for the sales of expensive prescription drugs.
Free markets work wonders, when they are properly structured so that there can be real competition. Every other large industrialized country in the world has found a way to provide high quality care to all their citizens while spending about half what the US spends per capita, and most of those countries do not have single payer systems (only Canada and England are single payer).
“free markets treat competition as damage and route around it”
> , the point is, you’re evading the simple reality that young healthy people often wind up bills that they *can’t* pay, and we all suffer the costs of that. All of us.
Reality check, Dean. This costs about the same as malpractice – not much. Maybe 2%.
It’s wrong to force people to buy expensive health insurance. People have the right to self insure – which Obamacare would deny. People have the right to buy catastrophic insurance – which Obamacare would deny.
Here’s what we can do though, to reform this. First, medical bills should not be retired through bankruptcy, since medical care cannot be denied. Second, make payment of those bills like child support – it comes out of your paycheck before you get paid.
It’s not failure to pay bills because of lack of insurance that really drives up costs.
It’s not malpractice.
It’s not lack of preventative medicine.
It’s third party payment causing people to demand Rolls Royce care.
It’s expensive technology that works.
It’s our refusal to give up.
We do have the best medical care in the world. We do keep trying when others give up. But it is expensive.
We want this. That’s why we have it.
What makes no sense is one set of rules for everyone in the U.S., a large and very diverse population. This should not be handled at the Federal level. Let the states handle it.
Yours,
Tom, aka Wince
Can you show me exactly where it says anyone goes to jail for not carrying health insurance?
Well, I guess I have to Dean’s Homework for him. Here it is, Dean, it took me all of two seconds to find it: http://tinyurl.com/ybs74q7
So basically, it means that you have to have health insurance or pay a fine and if you do not pay the fine you can go to jail. Not strained; clearly unconstitutional No where in the constitution does it give the Federal government the right to mandate to citizens to buy a product and if they do not fine or imprison them.
I know this won’t mean anything to State-worshipers like you, Aziz, or mikea because you’ll just argue that the crisis of the moment requires that we bulldoze these “silly rights”; but I remind you the darkest parts of our history involve the Federal Government bulldozing rights for the expediency of the moment.
And don’t give me that idiotic and strained argument that the precedent was set by requiring people to buy car insurance. You only need car insurance if you intend to own and drive a car if you prefer walking, mass transit or bumming rides you don’t need it; in this case if you expect to live as a free citizen (well, that should be “free”) you have to fork over your money to a business designated by the state whether you like it or not or you need it or not.
state-worshippers? LOL
its a measure of a weak argument if you are resorting to strawmen to argue against.
Thank you, Dean, for demonstrating the creeping logic of the welfare state. Every time the government takes on the role of shielding us from the natural consequences of our actions, it creates an argument to also deny us the right to take choices that have consequences. After all, if I make the wrong choice, then you wind up paying for it, so naturally you have a right to use the coersive power of the state to force me to take the actions you think are right.
I want the right to make my own choices, and I’m willing to deal with the consequences of my own actions. I’d rather not have other people butting into my personal business, justified by the possibility of them having to give me handouts that I never asked for.
Aziz, just going tit-for-tat with Dean who called those who oppose healthcare “reform” as “Market-worshipers”. In truth it is a lot easier to find state-worshipers than market-worshipers. Even the most ardent free marketer recognizes the state has some role in the market; but after each take over by the state of a certain part of the economy state-worshipers move onto the next “crisis” (before healthcare for all it was healthcare for “the poor”, before that it was retirement pensions). Next it’ll probably be “a University education for all” followed by “food for all” or “housing for all”
I wonder where it will end? Will we end with Denilov’s final words “Man will always be a man. There is no new man. We tried so hard to create a society that was equal, where there’d be nothing to envy your neighbour. But there’s always something to envy. A smile, a friendship, something you don’t have and want to appropriate. In this world, even a Soviet one, there will always be rich and poor. Rich in gifts, poor in gifts. Rich in love, poor in love. “?
mikeca,
Your points are all well taken. Thank you for your considered response.
This allows medical service providers to manipulate the system to maximize their profits, with only the insurance companies and the government as a check on this (by refusing to pay).
Agreed. For those situations, that’s the worst possible position for the buyer.
Do you really think that allowing the individuals to make more of these decisions will reduce cost? Individuals are less knowledgeable than doctors or health insurance/government bureaucrats. Individuals are easily manipulated by advertising. Just look at what drug advertising has done for the sales of expensive prescription drugs.
No, I don’t.
What I expect is:
1) People will be more frugal with money if some of it is their own.
2) Doctors will be more frugal if the one paying the tab is someone they have to look in the eye. I’ve seen this happen with my own doctors.
3) Some doctors and other suppliers/vendors will attempt to compete on a cost basis.
What I’m looking for is some way to change the overall culture of medical providers, and inject some measure of cost consciousness. I think there’s a lot of room to change mindsets.
Two more things I’d like to add to Dishman’s list:
4) Currently, many practicing doctors are ignorant of the costs of the tests and procedures they recommend (I have an HSA plan and ask about costs, which often leads to surprised and confused responses), which makes it hard for them to properly balance cost/benefit tradeoffs. By making patients aware of the costs, you make the doctors aware as well.
5) Veternary medicine is currently practiced in a system where most individual clients pay out-of-pocket, and most vets I’ve had experience with do an excellent job of giving their clients the information they need to make informed choices.
The question is will people be penny wise and pound foolish. Will they skip routine doctor visits or tests and end up with far more serious conditions.
Perhaps, but it might be easier to convince people to pay for expensive unneeded tests. Take for example the whole body scan rage. There is lots of expensive medical technology, and ordinary people are the least knowledgeable about when it is really needed.
This is probably true, but why doesn’t that happen today? If medicare payments are low, why haven’t some doctors found ways of providing services at such low cost that they make huge profits?
In the current system it is largely insurance/medicare bureaucrats making the cost benefit trade offs. Some doctors would do a good job with cost data, but some might seek to maximize there own profits at the expense of ordinary people.
I hope the goal is not to lower the health care standards for people to the same standards we use for pets.
With pets, we simply let them die, if their owners can or don’t want to pay for treatment. Are you suggesting we do the same for people?
Items I’m ready to respond to:
2) Perhaps, but it might be easier to convince people to pay for expensive unneeded tests. Take for example the whole body scan rage. There is lots of expensive medical technology, and ordinary people are the least knowledgeable about when it is really needed.
People inclined to manage their own health care expenses are probably more likely to be hard-nosed, having self-selected for that.
3) This is probably true, but why doesn’t that happen today? If medicare payments are low, why haven’t some doctors found ways of providing services at such low cost that they make huge profits?
I’ve looked at Medicare Reimbursement some. It appears to be structured in such a way as to prevent that. My opinion on the subject is worth the price you paid.
4) In the current system it is largely insurance/medicare bureaucrats making the cost benefit trade offs. Some doctors would do a good job with cost data, but some might seek to maximize there own profits at the expense of ordinary people.
I believe Eric and I are on the same page here. The thinking is not so much that everyone should have their health care expenses managed this way, but at least a sufficient number to bring awareness to the medical community. Eric and I are both doing our part already, but it would help there were more of us.
5) I hope the goal is not to lower the health care standards for people to the same standards we use for pets.
Please reconsider this in light of the above statements.
Eric:
Thank you, Dean, for demonstrating the creeping logic of the welfare state.
Except that it’s not “creeping,” if by that you mean an inexhorable pull toward 100% state dependence. What I’m actually illustrating the logic of is progressivism: gradually finding better and better solutions to life’s problems and progressive improvement in the human condition.
You have a obligations toward your fellow humans that go beyond common defense.
The fact is that if you find yourself in a position of needing serious medical help you can’t pay for, you’re likely to get it from someone anyway. That’s how the human animals work: we are not lone predators, we are pack animals. There is a social contract, and we all partake in it whether we want to admit it or not. You *are* shielded from the consequences of your own actions, constantly. The rest of us help you with that, whether you always recognize it or not. The only question in my mind, therefore, is how and where, in the most effective manner possible. “The market” is one of many possible answers, depending on the circumstances.
Mike:
Even the most ardent free marketer recognizes the state has some role in the market; but after each take over by the state of a certain part of the economy state-worshipers move onto the next “crisis” (before healthcare for all it was healthcare for “the poor”, before that it was retirement pensions). Next it’ll probably be “a University education for all” followed by “food for all” or “housing for all”
I’ve met a few who don’t recognize it at all, but most do. On the other hand, most ardent marketers still won’t admit that corporations are state-created, state-sustained entities that cannot possibly exist without government saying so, and thus can never be part of a *true* free market. But since a true free market probably can’t exist anyway, perhaps that’s not surprising. ;-)
Anyway, on all those benefits: We’re already there on most of it–and, amazingly, we are still not an oppressive hellhole. Indeed, our quality of life by almost any measure, including personal freedom, is at the pinnacle of human achievement to date. And, the world tried Communism and it didn’t work out, which is why most of the world’s democratic socialist nations still have thriving markets and have even had success expanding markets in the last generation or two.
I think it’s high time we give up the binary logic of “either communism or raw unfettered capitalism.” Both are pipe dreams. What should be at question is where collective action through governments is best, where collective action through corporations is best, and where individual action is best.
What I’m actually illustrating the logic of is progressivism: gradually finding better and better solutions to life’s problems and progressive improvement in the human condition.
Dean, when I look back at things that have found better and better solutions to life’s problems and improvements in the human condition over the past couple centuries, by far the biggest things I see are:
1. Enormous technological improvements which have vastly improved life expectency and quality of life. The have been primarily (not exclusively, but primarily) driven by the private sector.
2. Societal and legal changes to treat women and minorities as citizens with full rights to participate in society. The progressive movement deserves a fair amount of credit for this, but these improvements have been entirely independent of the growth of the welfare state, and have mostly taken the form of either social attitude changes (made outside of government) or the removal of legal barriers to equality.
It appears to me that improvements in human condition have been largely independent of or even despite of the actions of big government. The welfare state has expanded, but private sector improvements to society’s carrying capacity for the costs of the welfare state have outpaced the growth of government.
In this very thread, we’ve seen you argue that I shouldn’t have control over my health care because you’re appointed yourself my keeper, and MikeCa has argued that government or insurance-company bureaucrats should control my health care because I can’t be trusted to look after my own interests. That doesn’t sounds like continuous improvements to the human condition to me.
On the other hand, most ardent marketers still won’t admit that corporations are state-created, state-sustained entities that cannot possibly exist without government saying so, and thus can never be part of a *true* free market.
Corporations in their modern form — nearly-automatic chartering of corporations, available to anyone for a nominal fee with few strings attached — is a mechanism that evolved during the 18th and early 19th centuries in order to permit private investors to freely organize and compete to fill roles that were formerly filled by government monopolies or by powerful aristocrats. It may be an artificial construct, but it’s a fairly lightweight one which is orders of magnitude freer than the earlier alternative.
Indeed, our quality of life by almost any measure, including personal freedom, is at the pinnacle of human achievement to date. And, the world tried Communism and it didn’t work out, which is why most of the world’s democratic socialist nations still have thriving markets and have even had success expanding markets in the last generation or two.
Indeed, the countries in the world with the highest quality of life are the ones with the freest markets, followed by democratic socialist countries with functioning markets. Then, pretty far back, are highly socialist countries. The poorest countries of all are the ones with openly kleptocratic governments.
“The question is will people be penny wise and pound foolish. Will they skip routine doctor visits or tests and end up with far more serious conditions.”
There will always be people who are penny wise and pound foolish. People smoke. People eat too much. People hang glide and bungee jump. People rarely make the decision that promotes personal safety and well being 100% of the time. If everyone was forced to buy a government health plan, would that make it any more likely that people will be making routine doctor visits more often?
I know that various health fairs in poor or rural areas can draw many attendees, but they are also heavily promoted and advertised, and there is an air of an event or a happening that naturally draws a crowd. If everyone suddenly had health care, and there was no festival atmosphere, would Sally really pick some random Thursday and set aside time to go for her routine doctor visits and tests? I’m willing to be convinced otherwise, but my instinct is that there won’t be much of an increase in people making routine visits.
There is an argument that people shouldn’t be allowed to make their own choices because some of them might be penny wise and pound foolish. These penny wise people then end up with more expensive conditions later on. This is a problem, and government mandated health care is the way to solve this problem.
But what about those darn people who won’t utilize their “free” health care? If people not utilizing every opportunity for routine doctor visits and tests is a problem that we need to solve, are we going to somehow force people to make regular visits? Will we do it for their own good, sort of like making everyone buy government health care, for their own good?
And if we’re going to force people to buy health care, and force them to use it since, after all, we can’t allow people to make decisions that might cost society money (that’s why we can’t let healthy young people choose not to buy insurance, right?) then what about people who make bad eating choices?
No. How silly of me. Who ever heard of the notion of mandating what ingredients or cooking methods restaurants might use, or mandating what types of food might be allowed in what places? Oh wait, that is something that government is doing. They do it because people eating bad can lead to health consequences, and those consequences cost money to society.
Maybe government can come up with some sort of soy protein paste that will provide the appropriate nutrients for any individual, and we can just require people to eat only government paste and nothing else. It’s for their own good.
Of course, being in good physical condition also helps your health. Maybe we could mandate a regimen of physical exercise as well. But hiring trainers for everyone would be pretty expensive. Maybe we could come up with some sort of electronic training system that would provide one trainer for mmillions of people. Maybe like on TV. A government trainer could come on everyone’s TV and make them exercise each day.
But how would they know if Johnny is doing his exercises? I know! They could put some sort of viewer in place so that they can look through your TV screen and see whether or not you are doing your government mandated exercises. As an added benefit, they could also see if you are eating your government paste!
Can you imagine the sort of glorious utopia we will be living in when all of our decisions are made for us? What freedom!
What I’m actually illustrating the logic of is progressivism: gradually finding better and better solutions to life’s problems and progressive improvement in the human condition.
Progressive improvements to the human condition are almost completely due to things outside of what “progressives” have achieved. But this idea you are exposing is one of the central myths of progressivism. Just like those bumper stickers that say “you like your 40-hour work week? Thank Progressives!” or similar ones for weekends or minimum wage.
Nevermind these innovations were introduced and pushed in America by a Capitalist. A capitalist that was really responsible for building up America’s industrial base before the “Progressive” Unions (and bad managers) toppled it.
And no, there is no such thing as a “perfect” free market, but there is no such thing as “perfect” justice or “perfect” knowledge; but you don’t see people running around arguing that since the latter two don’t exist in their “perfect” form we should not bother trying to have a justice system. You do see “progressives” arguing that since the free market doesn’t exist in its perfect form we shouldn’t even bother valuing it.
On the other hand, most ardent marketers still won’t admit that corporations are state-created, state-sustained entities that cannot possibly exist without government saying so, and thus can never be part of a *true* free market.
Wrong, Dean, but with a slight twist you can get it right. Corporations are no more state-created, state-sustained entities than marriage is. A corporation at its core is simply a group of people operating together according to agreed upon rules. Without governments people could perform corporations and they did – they sold shares in an enterprise. Pirates did this entirely without governments. Their agreements gave various individuals varying shares of the booty. It’s the same thing.
Insert joke about corporate ethics and flying the jolly roger here.
That said, here’s the twist, and it’s one whose importance I’ve learned from you, Dean. As you have pointed out many times elsewhere, we don’t have a truly free market. There is a large body of law surrounding corporations, just like there is around marriage. These bodies of law are designed to benefit their respective institutions. One benefit has been that corporations have longer lives than many economic entities – although there have always been some very long lived family businesses.
I am flabbergasted by people who blythly want to get government out of the marriage business as a way to handle same-sex marriage. There is a huge body of family law surrounding marriage. We need that law to handle the inevitable disputes and controversies that arise.
Similarly we need corporate law to handle the inevitable disputes and controversies that arise.
Gone are the days when we could depend on the tribal elders to handle these disputes. Law is our substitute.
Yours,
Tom, aka Wince
1) People will be more frugal with money if some of it is their own.
The question is will people be penny wise and pound foolish. Will they skip routine doctor visits or tests and end up with far more serious conditions.
I hate this argument more than any other. The chances that skipping routine visits will end up costing more is far less than the chances that a routine visit will result in more tests, over treatment and over diagnosis and more cost for a greater number of patients.
I hope the goal is not to lower the health care standards for people to the same standards we use for pets.
With pets, we simply let them die, if their owners can or don’t want to pay for treatment. Are you suggesting we do the same for people?
I hope we get a grip on all the cruel and yes I do mean cruel treatments we inflict on our elderly dying population. Spend a night torturing a 95 y/o nursing home patient on her 4th MI with our treatments before you tell me we treat them better than our pets.
End of life care is I believe the greatest burden on the collective healthcare dollar and is the third rail that really ought to get a look see, but no one wants to go there.
End of life health care costs are in fact where the US system spends far more money than other industrialized countries. Any attempt to do anything about it though would be a death panel, so we can’t go there. Who was it that started talking about death panels? Those are the people who want to make sure nothing is done to restrain health care spending in any meaningful way.
Those are the people who want to make sure nothing is done to restrain health care spending in any meaningful way.
What a lovely, thoughtful way to characterize people who disagree with you.
End of life care is I believe the greatest burden on the collective healthcare dollar and is the third rail that really ought to get a look see, but no one wants to go there.
End of life care differs from failure to cure care, but they get lumped together in the stats. Let me ask you, did John Murtha’s (may he rest in peace) last gall bladder surgery count as end of life care? We need to separate out the American propensity to fulfill a true human dream by trying harder to save sick people. Some of that end of life care was spent trying to cure people whom we believe to have had an 80% chance of living. Some on 50%. Some 20%. Some 5%. Some 1% or less. Here’s the thing. By spending money on those low percentages we figure out how to increase them. That’s good for everyone on the planet.
You know, we could address this question via the market. I am going to brain storm a bit, so cut me some brain storming slack here. We could encourage insurance companies to offer plans which make those percentages explicit, and allow hospitals to deny care on that basis as well. An 20% plan would be cheaper than a 10% plan, which would be cheaper than a 1% plan, and the broader the Do Not Resuscitate order the cheaper as well. Uninsured people would be denied care based on income unless they can pay immediately. If you are penniless you are denied at 1%. If you are Warren Buffet you are denied at 100% unless you pay immediately. That way young Scrooge could choose a plan which would deny all treatments when he has a 20% or less chance of living and really save himself some money. I assume old Scrooge would take the Warren Buffet route. Post-ghost Scrooge would purchase 1% coverage on Tiny Tim.
Yours,
Tom, aka Wince
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